Adaptation and psychometric evaluation of the ENhancing Assessment of Common Therapeutic factors (ENACT) tool to build the capacity of primary care physicians in low-resource settings

Abstract Background With the global focus on task-sharing initiatives to bridge the treatment gap, the assessment of competencies of non-specialists is essential. The ENhancing Assessment of Common Therapeutic factors (ENACT) was developed to assess the competence of non-specialists to deliver psychosocial interventions, but the evidence regarding its application, implementation and adaptation process is limited. The present study aims to fill this gap by adapting and pilot testing the ENACT tool for resource-constrained settings. Methods and Results We used a sequential, mixed-methods approach to adapt and pilot test the ENACT tool for evaluating therapeutic skills of non-specialists trained in mhGAP trainings. The adaptation process consisted of selection of competencies through literature review and focus group discussion. This was followed by designing a test strategy comprising development of a case vignette, its iterative refinement and adapting scoring framework. Lastly, feasibility was tested in the mhGAP workshop setting. Eight competencies were retained based on their relevance, comprehensibility and feasibility. Each competency was rated on a four-point ordinal scale, with level 1 indicating no skill, while 2, 3 and 4 reflecting some, all and advanced skills, respectively. Role-plays were video-recorded and rated by trained raters. Good inter-rater reliability and significant correlation between competencies were observed. Discussion/Conclusion ENACT can be used to assess therapeutic skills but must be paired with structured rater training and contextual adaptation. Our study addressed its implementation challenges by making it manageable with limited resources, time and raters, making it scalable for low-resource settings. Our findings can inform mhGAP training design and delivery, facilitate in shifting its emphasis from a biomedical centered training to patient-centered approach. It can also guide curriculum refinement, identify priority skill areas for refresher trainings, and serve as mechanism for quality improvement for training and supervision. Lastly, it can inform policy decisions to integrate foundational competencies into large-scale training and supervision systems.